creating a successful program

Every program needs to take stock and decide are they on the right track or are they barking up the wrong tree. You also need to look at your "competitors" and see if they are doing something different from you and either directly compete with them or change the game and work around them. The first place to start is to look at the purpose of the organization. For corporations, the goal is simple - make money for shareholders and increase shareholder value. Given that we are a 501(c)(3) the goal is a little different. We do not have shareholders. We are not publicly traded. We do have a board of directors who give guidance but they look to each other and those running the organization to provide direction. For Cypress ECG we have come up with a simple goal statement

Provide low cost cardiac screening and increased awareness to reduce the incident of sudden cardiac death in teens. 

I hate it when people dissect sentences but I am going to do this. I think that it is important to talk about different ways of achieving this goal. There are basically three parts to this sentence.

1. Provide low cost cardiac screening
2. Provide increased awareness [of cardiac issues]
3. Reduce the incident of sudden cardiac death

"in teens"

All of these are related to teens and not adults or infants. Let's start with the easy question. Why teens? Why not infants? Pediatric Cardiologists are already focused on newborns and infants. There is a need for us to focus on anyone under the age of 11. There is adequate coverage with Pediatricians and Pediatric Cardiologists on this age group. Most kids under the age of 11 are not highly competitive and will stop participating when things get too difficult or things start to hurt. They are not as competitive and push their bodies harder than their systems can handle.

Why not adults? There are a large number of Cardiologists that handle this field. True that the age of most of their patients are older and typically in advanced stages of disease. We rely upon these Cardiologists to provide secondary screening and follow up visits. Unfortunately, most Adult Cardiologists are prohibited from seeing anyone under the age of 18 due to their malpractice insurance. There are ways around it but it requires the Cardiologists taking additional courses and notifying their insurance that they are planning on seeing patients under the age of 18. 

This leaves a gap of ages 11-18. This is the age where competition gets more difficult. Aggression gets higher with increased hormones. The heart changes from a pediatric heart to an adult heart. If genetics dictate a problem it will be manifested at this time. Unfortunately, this creates a double trouble situation. What was a healthy heart becomes sick due to physical changes. Competition gets more difficult resulting in additional stress on the heart. The symptoms of risk are sweating, being tired, dizziness, nausea, and shortness of breath and in extreme cases chest pain. With the exception of pain, these are also symptoms of heat exhaustion, dehydration, or being out of shape. Not only is there a need but there is a lack of coverage and available resources that can provide medical care to this age group.

"reduce the incident of sudden cardiac death"

This statement is a simple statement but spurs significant debate in the medical and athletic community. The first discussion is what is sudden cardiac death. We define it as anything resulting in death or near death caused by a cardiac related medical problem. Sudden cardiac death is differentiated from things like heart attack, injuries that cause cardiac issues, or diseases that lead to death through cardiac failure. Sudden cardiac death is called sudden because it is something unexpected that was not previously diagnosed. The typical causes that are related are hypertrophic cardiomyopathy, long Qt, Atrial Abnormalities, Axis problems, Conduction delay issues, Wolfe Parkinsons White Syndrome, and Ventricular problems. 

The word reduce is an inflammatory word as well. There is significant discussion on the incident of disease and how many deaths happen based on cardiac issues. We try not to take too strong a stand on this other than to say that the Texas UIL website is significantly on the high side stating that the risk is 1:300,000. Given that there are about 1.7 million high school students in Texas there should be five deaths per year across the state. Given that about 40-50% participate in athletics and that there were 8 deaths in 2010, the rate that is realistic based on recorded deaths is 1:85,000. Publications have honed these numbers down even more and stated that specific sports have a higher risk profile. Golf, for example, is the lowest risk sport. Other sports like cross country, swimming, and basketball have a higher risk profile of 1:3000 to 1:8000 because the heart is pushed harder and longer for these sports. 

Our goal is to see if we can screen all student athletes who are at elevated risk and reduce the number from 5-8 to 0-1. We realize that reducing the number to zero is difficult but a goal worth achieving. Given that we have found on average one student per year that has required surgery and one coach/adult every other year has had surgery we feel like we have reduced our target by at least one per year. 

The next controversial area is "low cost screening". When we analyze what is the highest cost in screening students, the doctor is the highest expense. A doctor can make $400-$500 per hour in their office or at the hospital. Having a doctor on site performing screenings takes on average 4-5 minutes per student. This means that one doctor can see about 20 students per hour if we assume 5 minutes. At $500 each screening would cost $25. If we add travel time we would triple or quadruple this number to $75 or $100 to cover just the time to travel to the remote location. The approach that we take is not to have the doctor on site but to reduce the time required by the doctor to apply their expertise. If we could get the time down to one minute per student then we can drop the cost to below $9 for a screening. If we can drop the time to below 30 seconds the cost drops below $5. 

The second controversy is the amount of testing that needs to be done. The absolute test that will show issues would be a transesophegual exam. Given that this is an $8,000 procedure and requires a trained Cardiologist to perform in a hospital environment, it is a bit impractical. The next level would be a genetic test which ranges from $100-$1000. This is also impractical. Both of these tests are typically used as a final test and not an initial test to examine risk and extent of cardiac issues. 

The two tests that can be performed are the ECG and the Echo. The ECG is an electrical test that can be done with volunteers or athletic trainers/nurses. The ECG machine cost $3000-$30,000 and has a consumable cost of $0.35 per screening. One machine can easily screen tens to hundreds of thousands of students so the cost can be amortized over the number of students screened. An Echo machine cost about 2 to 3 times the cost of an ECG machine. Given that we are doing resting ECGs and Echos we do not need the top end systems. An Echo machine needs a slightly higher trained user. Your typical nurse or Athletic Trainer can not perform a limited Echo. An Echotech is required. The cost of the Echotech is the largest cost in the equation. A typical ECG takes about 3-4 minutes to perform but an Echo takes 15-20 minutes. If we assume 15 minutes that means that someone getting paid $40 per hour can do four Echos at about $10 each. There really is not an easy way to reduce this cost because you can not screen any faster.

We have developed a program where we take ECG equipment to schools and have either trained full time staff perform the screenings or utilize the Nurses and Athletic Trainers to screen students. We ship the ECGs to our Cardiology staff and have them interpret the results. The full time staff communicates with the schools the interpretations to reduce the time needed by the doctors. We have elected to offer Echos as a second stage or optional part of screening. Using this methodology that we have submitted a patent on, we can charge $10-$15 for ECG screening and $25 for a combined ECG/Echo screening. 

Cypress ECG is in a position to provide low cost screening to any school in the state of Texas and is looking at expanding to other cities. In the next blog entry we will look at the way other organizations reduce the cost and provide screenings.

good week

August is a good time to screen students. Most schools in Texas start two-a-days and the new format this year lends itself well to screening students. We are about a third of the way into the month and have screened over 600 students for the month. We have screened at over twelve high schools this month and have been able to turn around most screenings in 48 hours. Many schools are using the "rest day" of two-a-days to have students come back up for screening in the afternoon since they can not practice the second afternoon. This is a good format. Most students are ready to get started and this gets volleyball and football players screened during one of their rest periods. It also gives the coaches a chance to talk to the kids and make sure that they hydrate the second day while standing in line waiting to get screened.

We are seeing tracking of about 4.5% of students needing a follow up and one in two thousand coming back as high risk. This basically means that 95% of students are cleared to participate. Having read all of the literature on screening and watching mass physicals this summer I can attest that the Washington University study stating that 87% of doctors do not ask students the required cardiac health and physical questions and many do not know how to hear a heart murmur. Having a cardiac screening to back up these programs gives parents and coaches a higher confidence level that the students are healthy enough for the rigors of two-a-days in the summer heat. True there might be some angst when they get a follow up request. Yes there is stress when a diagnosis comes back as high risk. What is the alternative? Do you really want someone on the field when they are high risk? If you know they are high risk would you let them participate? For the 4.5% that come back as a follow up request, about 20% come back as elevated risk but not high risk. About 5% come back as high risk of the follow up students. About 80% come back as something unusual but not high risk.

If you are not screening students this August or did not before the end of the school year ask yourself why not. If you are using an Orthopedist to do cardiac screening as part of your physicals you should use screening. If you are using an Nurse Practitioner or Chiropractor to perform physicals you should use screening. There is not cost to the school or athletic department to offer this service prior to participation. Cypress ECG offers the service to parents and comes to your facilities to screen. We typically see about 20% the first year if the screening program is supported and advertised by the coaching staff and administration. We have seen as high as 95% participation when it becomes an annual part of you physical process.

down the rabbit hole part 3

The bills are starting to trickle in. I am amazed by the cost of surgery and all of the procedures associated with it. To summarize for those just joining the discussion, I had a routine doctor visit last month and part of the visit was a routine ECG. The ECG showed classic atrial flutter and was confirmed with an ultrasound. When doing a stress ECG I actually went into Ventricle Tacacardyia  for a few heart beats as my heart raced to 300 beats per minute.

The initial doctor visit - $190 + $40 for ECG.
Secondary doctor visit - $190 + $400 for Echo and $400 for stress ECG
week 1 total - $1220.00

Visit with Electrophysiologist - $190 + $40 for ECG
Transesophageal echocardiogram (TEE) - $8000
week 2 total - $8320

Cardiac Ablation - $101,000
week 3 total - $101,000

month total - $110,540

Of this, the insurance company agreed to pay the hospital a pre-negotiated amount near $67,000 and asked me to pay about $4,000.

Let's put this in perspective. If I were part of a pre-participation screening program I would have gone to my school and had an ECG done for $15. If nothing were found, I would be done until four years later given that you only need to screen middle school and high school students once every four years. The alternative was to go to a doctor and get a routine physical which probably would not include and ECG. The doctor would have missed the atrial flutter because it sounds like a regular fast heart beat to someone not trained to listen for atrial flutter. The cost of the doctor visit would have been $75-$100 with a $25 copay. My out of pocket expense would have been $25 and I would continue participating and in all likelihood have collapsed on the field from dizziness or heart failure.

If something were found on the ECG, as it was in my case, I would have been labeled as follow up or high risk. In my case I would have been labeled as high risk. I would have gone to the Cardiologist and paid the $190 + $400 for the Echo and $400 for the stress ECG. This would have cost $15 for the screening ECG and $990 for the follow up exam. With the follow up exam, I would have paid my $25 co-pay and insurance would have picked up the rest. My out of pocket would be $40 to get screened in as a heart risk or screened out as clear to participate. Given that there was something there, I would have had the TEE performed as well as the Ablation at the same cost. As an aside, the TEE is a fascinating process. The doctor slips a small ultrasound machine down your throat and images your heart from inside your ribs. The pictures are much more accurate and can pick up blood clots and potential issues that could effect an ablation. I understand why this is not done as a screening protocol and requires a Cardiologist but the fact that they can slip an ultrasound machine inside the body and image the heart is interesting.

The alternative to screening was an ambulance/life flight ride, an emergency room visit, and emergency surgery. I don't know the cost of this option but my gut tells me that it is more expensive than just outpatient surgery that we scheduled ahead of time.

Given that we are three weeks after the surgery and I have started a routine of working out and loosing weight, I am glad that we performed the initial screening. I doubt that I would have been able to get back to bike riding, woodworking, and racket ball post emergency room visit as soon as I did with outpatient surgery.

Yes it was scary for my whole family that I had something wrong with my heart. Yes we started looking at things differently. Yes I am glad that I not only had the screening done but that we are providing it as a service for other people around the state.

pat

SWATA and Sudden Death

On July 19th I attended the Southwest Athletic Trainers Association annual conference. I was excited to attend because two of the talks were about sudden death and how to prepare/prevent it. This sounds like something that Cypress ECG would be interested in following and helping with.

The talk was moderated by Kenny Boyd of The University of Texas at Austin and keynote presenter was Katie Walsh of East Carolina University. Overall the talk was good but lacked emphasis where I feel it needed to be. The top eight causes of death listed are

1. Asthma
2. Concussions/Brain Injury
3. Spinal Injury
4. Diabetes
5. Heat Stroke
6. Sickle Cell reaction
7. Lightning
8. Sudden Cardiac Death

Given that Dr. Walsh is the US expert on lightning, the majority of the talk centered on detection, process and procedures, and the cost of monitoring. What was troubling was that Sudden Cardiac Death was not mentioned in the afternoon session and presented briefly in the morning session. 

Let's put things in perspective.

Asthma - about 8% of the population has asthma at all ages. Rates are higher for children below 18 with 9.5%. This means that one in ten kids statistically has asthma. Based on the CDC numbers about 90% of people diagnosed with asthma see a doctor for medication, 10% visit an emergency room on an annual basis, two percent are hospitalized, and less than one third of one percent die from the disease. The death rate for asthma is 0.15 per 1000 with the majority of those being in the 65 and older age group. For under 18 the rate is 0.09 per 1000 of those with the disease. This correlated to about one in 100,000 at risk for the under 18 age group.

Given that the equipment cost for Asthma is a Spirometer and medication that the student brings, schools can easily prepare for this but do need to perform baseline exams and record this information on the annual physicals. Many doctors will do this as part of the physical and if not athletic trainers or the school nurse can perform the screening for less than $200.

Concussion/Brain Injury/Spinal Injury - This is a topic that has had much discussion in the past two years and we don't need to go much more in depth here. The equipment for screening and testing of this is less than $1000 and is mandated by the state of Texas. 

Diabetes - About 10% of the population has diabetes. The number drops to less than 4% when you talk about under the age of 18. It is difficult to site death rates because diabetes causes other diseases like kidney failure, heart disease and stroke, and is the seventh leading cause of death in the US. Prevention and treatment is typically a glucose meter or something to measure blood sugar and does not exceed a few hundred dollars.

Heat stroke is another cause of death. Between 1999 and 2003 there were 3442 deaths, about 228 or 7% were under 15.  This puts the death rate at less than one per 100,000 in the general population and one per 1,000,000 in the under 18 age group. Treatment is simple if diagnosed early and properly. Most trainers know how to deal with this problem but it has been in the new lately as this has been a hot summer.

Sickle Cell is a genetic blood disorder that effects 50,000 US citizens annually. The disease is typically caught early and treated before the age of 3. Mortality rates in the US have dropped to less than one per 100,000 for this disease. The disease is significant in other countries and specific racial groups but a student in middle school or high school should know ahead of time if they have the disease and alert the medical and training staff prior to participation. No testing or screening equipment should be needed by schools, only treatment plans if a student has the genetic disorder.

Lightning is something that schools in Florida and Texas need to be wary of. During the thirteen year period from 1990-2003, 52 people died in Texas from lightning strikes putting the annual number of deaths in the general population at 4. The chances of death from lighting is one in 1,000,000. Schools in Texas are investing $6-$7K in early lightning detection systems to keep students safe. Events are delayed or cancelled. Participants and spectators are encouraged to seek shelter. Schools must develop an action plan because lightning will happen at some time while students are practicing, participating, or playing outside.

Sudden Cardiac Death is something that schools need to prepare for as well. In 2010 there were eight deaths from SCD in Texas. Given that there is no reporting mechanism by the state or the UIL it is difficult to track exact numbers.

Let's put things in perspective. Teen deaths are less than 1% of all deaths in the US. If a teen is going to die, the leading causes are

1. Auto accident (48% of all deaths)
2. Homicide (13%)
3. Suicide (11%)
4. Cancer (6%)
5. Heart Disease (3%)

From 1999-2006 there were 49.5 deaths per 100,000. This puts heart disease at 1.5 per 100,000 using the Center for Disease Control data. There are just over two million teenagers in Texas which means that there should be an average of 6 deaths per year in the teen population from heart disease.

I guess what I am getting at is that the SWATA Conference this year, the UIL Medical Advisory board for the past two years, the Texas Legislature, and the Texas Coaches Association have focused on the wrong things. Coaches have been focused on concussion screening since it was mandated by the Texas Legislature for most of 2011 and 2012 (relative risk 1:1,000,000). The UIL Medical board spent more time talking about restricting summer practices to avoid heat stroke (relative risk 1:1,000,000). SWATA invited in the leading expert on lighting and athletics to talk about planning and the value of a $7K warning system (relative risk 1:1,000,000). Nothing has been done or suggested by any of these organizations to help reduce the fifth leading cause of death, heart disease, for the school age population.

If schools are going to spend thousands of dollars on lightning warning systems, hundreds to thousands of dollars on baseline concussion screening, and hundreds to thousands of dollars to upgrade helmets and pads to reduce injury for one sport, spending $15-$25/student or asking parents to spend $15-$25/student for cardiac screening once while the student is in middle school and once while in high school should not be that much to ask. Event if money is the key issue, discussing the fact that current screenings with semi-annual physical questions, which are not used or wrong 87% of the time according to the University of Washington, warrants discussion by each of these groups. 

I guess that I am too passionate about this subject and am not seeing things clearly. If someone told me that there was a cheap and effective way to save five kids lives per year in Texas I would want to at least talk about it. 

down the rabbit hole part 2

Yesterday was an interesting day. I interviewed about 12 students who are about to finish their Echocardiography program at Lone Star College. We are expanding our services to include Echo exams because many schools are fine with ECG screening but others want Echo included. We recently purchased some portable Echo machines and need someone to operate them. It is relatively easy to train someone how to perform an ECG. Where to put the electrodes is the most difficult part but once you do a few hundred you get what is important and what is not. While I was on the operating table last week being hooked up for multiple ECGs, I talked to the nurse about placement of the electrodes. It turns out that their placement is critical and they need to think of things like having monitors for one doctor, monitors for another doctor, and a potential third for emergency situations. We had a long discussion on the placement of the V1 and V2 electrodes. It turns out that the placement of V3-V6 is not as critical as long as you get separation and coverage of the heart. The V1 and V2 placement is a little more critical when a metal object will be inserted into the heart from a vein in the groin area.

When I tried to engage the Echo students about ECG placement, many of them had no clue because they have seen the procedure done but have never done it themselves. It made me realize how specialized we are all becoming and don't understand the basic concepts of everything. I understand a little more about IV placement and why you don't want to re-insert an IV into the same area the next day. I had trouble talking the students lingo when describing the views that we are looking for and realized that I know the term injection fraction but don't know how to measure it. I was able to explain that we are primarily looking for wall thickness and valve structure with an Echo. I could also explain that the medical industry is significantly divided when it comes to what diseases you can find with ECG and what you can find with Echo. What most doctors agree on is that you can catch cardiac disease with screening. Most agree that ECG is a good tool for looking at LongQT and arrhythmias. Echo is the tool to look at wall thickness. Both are good at looking at Brugada Syndrome.

What surprised me most about having an ablation done is how easy the recovery time was. I had the surgery on Friday and Sunday morning I was walking the neighborhood. I went for a bike ride on Tuesday (just to the store to see how it felt) and am ready for a more challenging ride. I now understand why an athlete is ready to get back into the game and start training for the next event. The surgery is complex but low impact on the body. There wasn't a large scar that I had to put a new bandage on every day. I can barely find there the incision was and do not have lingering effects of muscle ache from the surgery. I do have two large bruises that I got from injections of blood thinner but these will go away in time.

I am convinced that screening is something that everyone should do. Early detection is the key to simple treatment. I keep playing different scenarios in my head about alternative outcomes and early screening with preventative surgery is the best case option I can think of. I will summarize the cost of screening and treatment in later weeks as bills come in and help me document my experience.

Our next screening events are at the end of July as football players start returning to campus for summer workouts. As my son starts swimming for his new school I will as a parent pressure the coaches to screen their students. Given that swimming is one of the high risk sports I will work to educate the coaches on the risks and how easy it is to screen to avoid them. My advice is to call your athletic director or head coach and ask why they are not offering screening to their students and parents. It does not cost the district anything and parents can choose to participate or not. Not offering it is admitting that it is not something important and the medical community admits that it is something worthy of looking for but disagrees on the cost of looking and what tests are needed.

from the other side of the looking glass

When I started working at a computer company, I read everything, build my own computers, took extra computer classes, and did what I could to become an expert on the topic of computers. I wanted to make sure that I knew everything about computers and how they worked before getting too far along. When I started working on the ECG project, I did not think that it was possible to figure out everything about the technology, how the heart works, what different diseases are, and surgical processes to correct cardiac issues. I dove into accounting, starting a business, writing a business plan, interviewing techniques, and details about becoming a 501(c)(3) company. Little did I know that I would be looking at cardiac screening with the same zeal and interest as I did computers.

Two weeks ago I scheduled an annual cardiology exam because I was thinking of going to summer camp with the Boy Scouts like I have for the past ten years. Little did I know that something as simple as an ECG would show that I had an irregular heart beat, specifically atrial flutter. The phrase from the hair club for men immediately came to mind, "I'm not just the president, I am a member". For two years we have been traveling the state performing ECGs on students looking for the one in two thousand that would be at risk, talking of warning signs, lobbying on what should be done, and talking to Cardiologists around the state to schedule follow up limited Echos. Not wanting to be a hypochondriac, I dismissed the symptoms because I was talking about it so much. Dizziness while exercising. Tightness in the chest that could be mistaken for muscle fatigue. Shortness of breath. I attributed all of these to being overweight and out of shape. I was exercising to get back in shape and thought that it was just a little more difficult this time since I was getting older.

Good thing that I scheduled a checkup.

Phase two of screening after an abnormal ECG is an Echo. My condition would have been labeled as follow up but can continue to participate with a limited Echo. Given that I work with a Cardiologist and am not a teenager, the diagnosis was not a limited Echo but a stress Echo with a treadmill and all the fun associated with that. After four hours reading various web sites and publications on what a flutter actually is I think that I understand it as well as the potential causes for it at my age. I thought that I was ready for the treadmill and a stress echo. I had done one fifteen years ago and was not looking forward to running as fast as I can to drive my heart rate up to 170 beats per minute. Fifteen years ago I was a marathon runner and needed to run much faster than I wanted to for the heart rate target. This time I was at 170 and climbing within four minutes and I was just starting to walk fast.

Good thing that I schedule a checkup.

Having done miserably on the stress Echo I learned phrases like ventricular tachycardia and arrhythmia from a different perspective. They were no longer wiggles on a trace. They were no longer a diagnosis that a doctor wrote down and I translated this to a student at a school in another city. It was not something that I had to explain to a trainer and tell them look out for excessive sweating, dizziness, and fatigue. It was something that I had to explain to my wife and kids. I started thinking things like is my insurance up to date, can I take a few days off for doctor visits, when can I get surgery scheduled.

Good thing that I schedule a checkup.

For the next week I will get to experience an ablation from the patient side. I will understand what a catheterization means and what it takes to recover from one. I will see things from the other side of the looking glass. I would much rather deal with secondary exams, talking to doctors about procedures, and taking a few days off for a day surgery. Yes, I am a little scare that a doctor will be opening up a vein in my leg and inserting a medical device into my heart while it is beating and short circuit a signal that is causing an extra heart beat in the top half of my heart. Yes, I am nervous about recovery time and limitations placed on me while I recover. Yes, I realize how lucky I am that a simple ECG kept me from going into cardiac arrest and getting to experience an emergency room for the first time. This is something that I hope to avoid for another quarter century or more.

Yes, I understand the importance of cardiac screening.

Pat Shuff
Chief Operating Officer
Cypress ECG

Legislation around the country

I am amazed by what legislation is being discussed around the nation. Doing a quick search for the word cardiac turns up

• links to Good Samaritan laws for every state
• links to AED legislation for every state
• school usage of AED for every state
• second link for AEDs in schools

It is a little depressing that the bulk of the legislation talks about emergency response and protecting care givers and does not focus on detection or prevention. The only forward looking legislation that I could find is

• New Jersey - A1863 - New Jersey Student Athlete Cardiac Screening Task Force
• New Jersey - S1911 - Children's Sudden Cardiac Events Reporting Act
• Pennsylvania - HB 1610 - Establishes standards for preventing sudden cardiac arrest and death in student athletes

With the passage of the bill in Pennsylvania to define the symptoms of cardiac issues and mandate what coaches and trainers should do when these symptoms appear, there is hope that other states will follow this lead. Texas passed similar laws for concussions last year. Hopefully we can help them pass a similar law for cardiac symptoms.